Needle Phobias
 

Psychologists are sharing interventions and therapies to help patients whose fear of needles could stop them from getting a COVID-19 vaccine. (2021)

(Direct link to article here.)

By Charlotte Huff

Since COVID-19 first emerged, Matthew Noles has fretted that the best news for science and humanity—a vaccine breakthrough—would come at a personal emotional cost.

Just thinking about needles conjures up what Noles admits are irrational fears. In the weeks before his first COVID-19 shot in February, he worried that he would be confronted with a needle the width of a meat injector, or that the nurse would trip while administering the injection, sending the needle deep into his arm.

“I know these things are not going to happen, but they still pop into my head,” said the 42-year-old Alabama resident. While getting his first dose on Feb. 10, Noles had a vasovagal response to the needle procedure. He passed out and someone called an ambulance.

Such anxieties are not rare, and they can discourage important medical care. One meta-analysis found that 8% of health care workers in hospitals and 18% of workers in long-term care facilities avoid the influenza vaccine due to needle fears (McLenon., J., & Rogers, M. A. M., Journal of Advanced Nursing, Vol. 75, No. 1, 2019). A Canadian study, based on a survey of Toronto parents and children, found that 7% of adults and 8% of children reported needle fears as the primary reason for not receiving recommended immunizations (Taddio, A., et al., Vaccine, Vol. 30, No. 32, 2012).

Now people like Noles must weigh long-standing fears about needles and injections versus the life-saving benefits of an effective vaccine against a highly contagious virus. For patients who seek help, psychologists can provide exposure therapy for the most fearful and pain management strategies, including distraction, positive reframing, and the use of numbing creams, for those with lower-level fears.

It's unclear to what degree injection fears will discourage people given the stakes involved in the COVID-19 pandemic, said Kathryn Birnie, PhD, a clinical psychologist and assistant professor at the University of Calgary in Alberta, Canada. But given the importance of having as much of the population vaccinated as possible, psychologists should be prepared to help patients who acknowledge such fears and ready to offer guidance to health care professionals who may encounter these patients, according to psychologists with expertise in needle fears and pain management. These fears can be inhibiting even if patients don’t meet the diagnostic criteria for a blood injection injury phobia, said Meghan McMurtry, PhD, an associate professor in psychology at the University of Guelph in Ontario, Canada.

If patients have high levels of needle fear, “tending toward avoidance or very high distress during procedures,” psychologists need to try to help them, said McMurtry. Exposure therapy likely will be needed, she said, as pain management strategies alone “don’t tend to work when you have high, high levels of that anxiety and that fear.”

The needle spectrum

Feeling cautious about injections and blood draws “is relatively normal,” McMurtry said. “There is something being injected in or taken out of your body,” she said. “There is some pain involved.”

More significant injection fears may be connected to a negative experience, more likely in the preschool years when vaccines are common, Birnie said. Children, in particular, can be influenced by fearful talk from those around them, such as siblings, parents, or clinicians. Imagery in popular media and news reports can also spark fears, she said. In 2019, Self magazine partnered with the American Academy of Pediatrics to compile a resource of free stock photos that media can use that lack depictions of crying children and oversize needles.

Adults with significant anxiety may postpone or skip a vaccine or blood procedure, and children may outright refuse to have one, McMurtry said. Those patients with an even higher degree of fear or a diagnosable phobia may experience a vasovagal response like Noles did.

The vasovagal reaction itself stems from the patient’s heart rate and blood pressure revving up and then dropping abruptly. The result can be that the patient faints or experiences other symptoms, including dizziness, nausea, or sweating.

On that February day, Noles initially felt fine after the nurse told him he was done. “I took this huge exhale,” he recalled, before walking to the waiting area where patients were monitored for any post-injection reactions.

“Within three minutes, I could feel that my whole body felt numb and kind of tingly,” he said. “I was struggling to breathe. My vision was all out of whack. I could feel everything slowing down.”

Tackling COVID-19 vaccine fears

One challenge with easing injection fear compared with other phobias, such as a fear of dogs, is that people can avoid vaccines or other needle interactions for many years, said Lindsey Cohen, PhD, chair of psychology at Georgia State University in Atlanta.

Given the urgency of vaccine uptake right now, Cohen advises that psychologists talk to patients who are struggling with injection fears about their values and goals to increase motivation. Do they want to master their injection fears because they are interfering with their life or do they want to learn strategies to simply get through the COVID-19 vaccination process?

If the latter is the case, Cohen said, “you can probably teach them some quick and easy coping techniques so they feel some mastery” prior to the vaccination, ticking off deep breathing, progressive muscle relaxion, or imagery as possibilities. A patient’s history with injections should also inform treatment, such as if they have had a vasovagal response in the past.

Cohen also suggests developing a plan with each patient to think through all the pieces of the vaccine encounter. Would the patient be more comfortable knowing in real time what the nurse is doing, including getting a heads-up before the shot is given? Or would they prefer to distract themselves as much as possible by watching a video or listening to music through headphones? The patient should then express those preferences and ask for help from whomever is administering the vaccine, he said.

The potential benefit of distraction, Birnie said, “ is that our brain has only so much capacity to pay attention to any one thing. A high level of fear will override that. But in the context of lower levels of fear, distraction is really helpful.”

The two-dose regimen involved with some of the initially approved COVID-19 vaccines can pose additional stress for needle-averse patients, Birnie said. But psychologists can work with patients on positive reframing, focusing on what went well with the first dose or with the last injection they can remember. “If we remember things in a really horrible, distressing way, we’re more likely to expect that they’ll go worse next time,” she said.

Psychologists can also encourage patients to practice positive self-talk during the procedure itself, Birnie said. “Even saying to yourself during it, ‘I can do this’ or ‘I’m doing this because it’s important to me to get the vaccine.’ Any positive statement that helps them.”

Birnie also tells patients that there are numbing creams sold over the counter that can lessen the pain of the injection if they apply them 30 minutes to an hour ahead. She advises psychologists to work with patients on deep breathing techniques they can use during the procedure to reduce their fight-or-flight response as well as the tension in the muscle area where the vaccine will be injected.

“The distress and pain are highly related to each other,” Birnie said. “The more distressed [patients] are, the more tense they are holding their body.”

Addressing diagnosable needle phobia

Studies indicate that 3% to 4% of people qualify as having a needle phobia, which is characterized by avoidance behavior, intense irrational fear, and the risk of becoming dizzy or fainting, either during or in anticipation of a procedure (Wani, A. L., et al., Behavioural Neurology, 2014). But that figure is likely underestimated given that such individuals often avoid the health system in the first place, McMurtry said.

Patients like Noles who have had a vasovagal reaction to an injection can be taught a technique that uses muscle tension to help boost their blood pressure, McMurtry said. The applied tension technique, which was developed by Swedish clinical psychologist Lars-Göran Öst, PhD, relies on patients tensing up major muscle groups, such as leg or stomach muscles, for roughly 10 to 15 seconds until their face feels flushed or warm, followed by relaxing the muscles back to baseline for 20 to 30 seconds. By activating those muscles, and repeating the process until the procedure is over, the goal is to keep the patient’s blood pressure high enough to avoid fainting, McMurtry said.

For individuals who want to overcome a diagnosable phobia or high levels of fear, research indicates that exposure therapy is likely the optimal approach, McMurtry said. She helped write a clinical guideline that recommended using exposure-based therapy to treat high levels of injection fear in children age 7 and older and in adults (McMurtry, C. M., et al., Cognitive Behaviour Therapy, Vol. 45, No. 3, 2016).

During exposure therapy, a psychologist works with the patient to develop a hierarchy of exposures, starting with something that causes minimal anxiety and then increasing that exposure, McMurtry said. But first, the psychologist helps the patient sort out the underlying focus of the fear, whether that’s pain or blood exposure or the look of the needle itself, she said. With that focus in mind, then the hierarchy of exposures can be developed.

In one scenario, a patient may begin with images of needles, first looking at line drawings and then at more realistic depictions, McMurtry said. Later, the exposure may involve handling a plastic needle or giving a stuffed animal an injection, before moving on to more direct exposures, such as watching someone else get a shot, she said.

Though exposure therapy may be completed in a single, longer session, it often requires multiple sessions and exposures, McMurtry said. Above all, it’s a stair-step process that cannot be short-circuited, she stressed.

Through these exposures, the patient will learn to conquer their out-of-proportion fears by realizing either that the feared outcomes won’t materialize or that they will survive them. It’s crucial that the patient does not quit exposure therapy early, whether by dropping out of therapy or by closing the book on pictures of anxiety-producing needles, because doing so will perpetuate their fear by continuing the avoidance loop, McMurtry said.

“They go up the worry hill and then they escape at the highest point,” she said. “So they don’t learn that the fear is going to come down.”

If people do not get help, the risk is that these fears will worsen, particularly given that many people get vaccines infrequently once they reach adulthood, Cohen said. Thus, they don’t reap the benefits of periodic natural exposure, he said. “The whole time they can be building up their cognition and fears about it without any counterevidence.” Having a successful injection can help stop the buildup of that fear, even if the bar for success is simply making it through the injection.

Despite his rocky first dose, Noles was determined to get the second. This time, the vaccine site allowed his wife to accompany him, and he didn’t pass out. He reported back triumphantly via text: “I did MUCH better this time.”